Methods for treating diabetic foot ulcers

ABSTRACT

The present invention provides methods and pharmaceutical formulations for treating diabetic foot ulcers.

CROSS REFERENCE

This application is a continuation of U.S. application Ser. No.13/364,061 filed Feb. 1, 2012 which claims priority to U.S. ProvisionalPatent Application Ser. No. 61/438,780 filed Feb. 2, 2011, incorporatedby reference herein in their entirety.

BACKGROUND

Diabetes is common, disabling and deadly. In the U.S., diabetes hasreached epidemic proportions. According to the American DiabetesAssociation, about 24 million people (8% of the total U.S. population)have diabetes, and nearly two million new cases are diagnosed in peopleaged 20 years or older each year. If current trends continue, 1 in 3Americans will develop diabetes at some point in their lifetime, andthose with diabetes will lose, on average, 10-15 years of lifeexpectancy. Importantly, up to 25% of people with diabetes will developa diabetic foot ulcer, resulting in 3 million diabetic foot ulcersannually in the U.S. alone. More than half of all foot ulcers willbecome infected, thus requiring hospitalization, and 1 in 5 will requirean amputation that carries a high risk of mortality.

Without question, diabetes puts tremendous economic pressure on the U.S.healthcare system. Total costs (direct and indirect) of diabetes havereached $174 billion annually, and people with diagnosed diabetes havemedical expenditures that are over two times higher than medicalexpenditures for people without diabetes. Hospitalization costs aloneare $16,000 to $20,000 for a patient with a diabetic foot ulcer, anddirect and indirect costs of an amputation range from $20,000 to $60,000per patient. A recent study by researchers at the University of Chicagosuggested that treatment costs for diabetes in the United States wouldreach $336 billion by the year 2034. Advanced, cost-effective treatmentmodalities for diabetes and its co-morbidities, including diabetic footulcers, are in great need, yet in short supply, globally. According tothe American Diabetes Association, by the year 2025 the prevalence ofdiabetes is expected to rise by 72% to 324 million people worldwide.

SUMMARY OF THE INVENTION

In a first aspect, the present invention provides methods for treatingdiabetic foot ulcers, comprising administering to a human patientsuffering from a diabetic foot ulcer an amount of a peptide of at least5 contiguous amino acids of Nle3 A(1-7), or salt thereof, effective totreat the diabetic foot ulcer. In one embodiment, the peptide comprisesAsp-Arg-Nle-Tyr-Ile-His-Pro (SEQ ID NO:1), or salt thereof. In anotherembodiment, the peptide consists of Asp-Arg-Nle-Tyr-Ile-His-Pro (SEQ IDNO:1), or salt thereof. In various embodiments, the diabetic foot ulceris one caused, at least in part, by neuropathy and resulting pressure;the diabetic foot ulcer comprises one or more calluses; and the diabeticfoot ulcer is a chronic ulcer. In a further embodiment, the chronic footulcer has not responded to any other treatment.

In another embodiment, the peptide is administered topically. In afurther embodiment, the peptide is administered as a topical formulationforming a continuous film covering the entire area of the diabeticulcer. In a still further embodiment, the peptide is administered in ahydrogel formulation. In another embodiment, the peptide is administeredat a concentration of about 0.03% to about 1% on a weight (mg)/volume(ml) basis, or on a weight/weight (mg) basis. In a further embodiment,the peptide is administered in a gel formulation that about 0.5% toabout 4% hydroxyethyl cellulose (HEC) on a weight (mg)/volume (ml)basis, or on a weight/weight (mg) basis.

All embodiments of the first aspect of the invention can be combinedunless the context dictates otherwise.

In a second aspect, the present invention provides pharmaceuticalformulations, comprising:

(a) about 0.5% to about 4% HEC on a weight (mg)/volume (ml) basis, or ona weight/weight (mg) basis; and

(b) a peptide of at least 5 contiguous amino acids of Nle3 A(1-7), orsalt thereof;

wherein the peptide is present at a concentration of about 0.03% toabout 1% on a weight (mg)/volume (ml) basis, or on a weight/weight (mg)basis.

In one embodiment, the peptide comprises Asp-Arg-Nle-Tyr-Ile-His-Pro(SEQ ID NO:1), or salt thereof. In another embodiment, the peptideconsists of Asp-Arg-Nle-Tyr-Ile-His-Pro (SEQ ID NO:1), or salt thereof.In a further embodiment, the pharmaceutical formulation comprises about1% to about 3% HEC on a weight (mg)/volume (ml) basis, or on aweight/weight (mg) basis. In a still further embodiment, thepharmaceutical formulation comprises about 2% HEC on a weight(mg)/volume (ml) basis, or on a weight/weight (mg) basis. In anotherembodiment, the formulation comprises a hydrogel formulation. Allembodiments of the second aspect of the invention can be combined unlessthe context dictates otherwise.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 is a graph showing the ulcers healed by visit in the Per Protocol(PP) patient population taking NorLeu³-A(1-7).

FIG. 2 is a graph showing the percentage of fully healed ulcers (100%wound closure) in the patient population taking NorLeu³-A(1-7) (alsoreferred to as “DSC127”).

FIG. 3 is a graph showing the median time to fully healed ulcers (100%wound closure) in the patient population taking NorLeu³-A(1-7) (alsoreferred to as “DSC127”).

DETAILED DESCRIPTION OF THE INVENTION

All references cited are herein incorporated by reference in theirentirety. Within this application, unless otherwise stated, thetechniques utilized may be found in any of several well-known referencessuch as: Molecular Cloning: A Laboratory Manual (Sambrook, et al., 1989,Cold Spring Harbor Laboratory Press), Gene Expression Technology(Methods in Enzymology, Vol. 185, edited by D. Goeddel, 1991. AcademicPress, San Diego, Calif.), “Guide to Protein Purification” in Methods inEnzymology (M. P. Deutshcer, ed., (1990) Academic Press, Inc.); PCRProtocols: A Guide to Methods and Applications (Innis, et al. 1990.Academic Press, San Diego, Calif.), Culture of Animal Cells: A Manual ofBasic Technique, 2^(nd) Ed. (R. I. Freshney. 1987. Liss, Inc. New York,N.Y.), Gene Transfer and Expression Protocols, pp. 109-128, ed. E. J.Murray, The Humana Press Inc., Clifton, N.J.), and the Ambion 1998Catalog (Ambion, Austin, Tex.).

As used herein, the singular forms “a”, “an” and “the” include pluralreferents unless the context clearly dictates otherwise. “And” as usedherein is interchangeably used with “or” unless expressly statedotherwise.

All embodiments of any aspect of the invention can be used incombination, unless the context clearly dictates otherwise.

In a first aspect, the present invention provides methods for treatingdiabetic foot ulcers, comprising administering to a human patientsuffering from a diabetic foot ulcer an amount of a peptide of at least5 contiguous amino acids of Nle3 A(1-7), or salt thereof, effective totreat the diabetic foot ulcer.

As demonstrated in the examples that follow, the inventors havedemonstrated that the methods of the invention can be used to treatdiabetic foot ulcers, and provide substantial improvement over standardtherapies.

Nle3A(1-7) (or NorLeu³-A(1-7); also referred to as “DSC127”) is apeptide consisting of the amino acid sequenceAsp-Arg-Nle-Tyr-Ile-His-Pro (SEQ ID NO:1). In various embodiments, thepeptide administered to the human patient may comprise or consist ofAsp-Arg-Nle-Tyr-Ile (SEQ ID NO:2), Asp-Arg-Nle-Tyr-Ile-His (SEQ IDNO:3), or most preferably Asp-Arg-Nle-Tyr-Ile-His-Pro (SEQ ID NO:1), orsalts thereof. Nle3A(1-7) or salts thereof may be chemically synthesizedor recombinantly expressed, each of which can be accomplished usingstandard methods in the art.

In one embodiment, the peptide, or salt thereof, is administered at aconcentration of about 0.03% to about 1% on a weight (mg)/volume (ml)basis, or on a weight/weight (mg) basis. In various further embodiments,the peptide, or salt thereof, is administered at a concentration ofabout 0.03% to about 0.75%; about 0.03% to about 0.5%; about 0.03% toabout 0.25%; about 0.03% to about 0.1%; about 0.03% to about 0.075%;about 0.03% to about 0.05%; and about 0.03%; all on a weight (mg)/volume(ml) basis, or on a weight/weight (mg) basis.

The human patient may be suffering from Type I diabetes or Type IIdiabetes, and has a foot ulcer, defined as an open wound anywhere on thefoot (heel, mid-foot, and forefoot).

As used herein, “treating” a diabetic foot ulcer includes

(a) limiting the progression in size, area, and/or depth of the footulcer;

(b) reducing size, area, and/or depth of the foot ulcer;

(c) increasing rate of healing and/or reducing time to healing;

(d) healing of the foot ulcer (100% epithelialization with no drainage);and

(e) decreased incidence of amputation or slowing in time to amputation.

The foot ulcer may be caused by any underlying pathology, including butnot limited to neuropathy, trauma, deformity, high plantar pressures,callus formation, edema, and peripheral arterial disease. In preferredembodiments, the human diabetic foot ulcer is one caused, at least inpart, by neuropathy and resulting pressure (weight bearing on theextremity due to lack of feeling in the foot). As is known to those ofskill in the art, human diabetic foot ulcers tend to be due toneuropathy and pressure, which differs significantly from, for example,murine acute wounds. In a further preferred embodiment, the diabeticfoot ulcer comprises one or more calluses.

In a further embodiment, the diabetic foot ulcer is a chronic ulcer. Asused herein, a “chronic” foot ulcer is one that has been present for atleast 7 days with no reduction in size; preferably at least 14 days;even more preferably, present at least 21 or 28 days with no reductionin size. In a further preferred embodiment that can be combined with anyof these embodiments, the chronic foot ulcer has not responded (ie: noreduction in size, area, and/or depth of the foot ulcer; no healing ofthe foot ulcer) to any other treatment.

The peptide or salt thereof may be administered by any suitable route,preferably via topical administration. In one embodiment, the methods ofthe invention can comprise administering a topical formulation as oftenas deemed appropriate, ie: once per day, twice per day, etc. The methodsmay further comprise administration of the peptide, or salt thereof foras longed as deemed desirable by an attending physician, for example,until healing of the ulcer. For administration, it is preferred that thetopical formulation form a continuous film covering the entire area ofthe ulcer, including the margins. In a preferred embodiment, the topicalformulation is applied with a thickness of approximately 0.25 to 2 mm;preferably 0.5 to 1.5 mm; preferably about 1 mm in thickness.

In one embodiment, the topical administration comprises administrationin a formulation selected from the group consisting of hydrogels,creams, ointments, pastes, and lotions. The formulations may be appliedin any suitable manner, which may include any wound dressings to seal inthe formulation deemed appropriate by the human patient or caregiver.Exemplary such dressings, include, but are not limited to, semipermeablefilms, foams, hydrocolloids, and calcium alginate swabs.

The methods may further comprise debridement in and around the wound incombination with administration of the peptide and formulations thereof.Debridement of all necrotic, callus, and fibrous tissue is typicallycarried for treatment of diabetic foot ulcers. Unhealthy tissue issharply debrided back to bleeding tissue to allow full visualization ofthe extent of the ulcer and to detect underlying abscesses or sinuses.Any suitable debridement technique can be used, as determined by anattending physician. The wound can then be thoroughly flushed withsterile saline or a non-cytotoxic cleanser following debridement.

In another embodiment, the topical formulation comprises about 0.5% toabout 4% hydroxyethyl cellulose (HEC) on a weight (mg)/volume (ml)basis, or on a weight/weight (mg) basis. In various further embodiments,the topical formulation may comprise about 1% to about 3% HEC, or about2% HEC, on a weight (mg)/volume (ml) basis, or on a weight/weight (mg)basis. These formulations comprising low percentage HEC (ie: 2%)matrices provided a 10-fold increase in peptide release over a 24 hourperiod from formulations such as those comprising 10%carboxymethylcellulose (CMC), a result that would be unexpected to thoseof skill in the art. Furthermore, the data show that the HEC matricesare more biocompatible than HPMC and CMC formulations tested.

The peptides, or salt thereof may be administered together with one ormore (a) a lyoprotectant; (b) a surfactant; (c) a bulking agent; (d) atonicity adjusting agent; (e) a stabilizer; (f) a preservative and/or(g) a buffer. In some embodiments, the buffer in the pharmaceuticalcomposition is a Tris buffer, a histidine buffer, a phosphate buffer, acitrate buffer or an acetate buffer. The peptides may be administeredwith a lyoprotectant, e.g. sucrose, sorbitol or trehalose. In certainembodiments, the peptides may be administered with a preservative e.g.benzalkonium chloride, benzethonium, chlorohexidine, phenol, m-cresol,benzyl alcohol, methylparaben, propylparaben, chlorobutanol, o-cresol,p-cresol, chlorocresol, phenylmercuric nitrate, thimerosal, benzoicacid, and various mixtures thereof. In other embodiments, the peptidesmay be administered with a bulking agent, like glycine. In yet otherembodiments, the peptides may be administered with a surfactant e.g.,polysorbate-20, polysorbate-40, polysorbate-60, polysorbate-65,polysorbate-80 polysorbate-85, poloxamer-188, sorbitan monolaurate,sorbitan monopalmitate, sorbitan monostearate, sorbitan monooleate,sorbitan trilaurate, sorbitan tristearate, sorbitan trioleaste, or acombination thereof. The peptides may be administered with a tonicityadjusting agent, e.g., a compound that renders the formulationsubstantially isotonic or isoosmotic with human blood. Exemplarytonicity adjusting agents include sucrose, sorbitol, glycine,methionine, mannitol, dextrose, inositol, sodium chloride, arginine andarginine hydrochloride. In other embodiments, the peptides may beadministered with a stabilizer, e.g., a molecule which, when combinedwith the peptide substantially prevents or reduces chemical and/orphysical instability of the protein of interest in lyophilized or liquidform. Exemplary stabilizers include sucrose, sorbitol, glycine,inositol, sodium chloride, methionine, arginine, and argininehydrochloride, paraben, and combinations of methyl paraben and propylparaben.

In all aspects and embodiments of the invention, suitable acids whichare capable of forming salts with the peptides include, but are notlimited to, inorganic acids such as hydrochloric acid, hydrobromic acid,perchloric acid, nitric acid, thiocyanic acid, sulfuric acid, phosphoricacid and the like; and organic acids such as formic acid, acetic acid,propionic acid, glycolic acid, lactic acid, pyruvic acid, oxalic acid,malonic acid, succinic acid, maleic acid, fumaric acid, anthranilicacid, cinnamic acid, naphthalene sulfonic acid, sulfanilic acid and thelike. Suitable bases capable of forming salts with the peptides include,but are not limited to, inorganic bases such as sodium hydroxide,ammonium hydroxide, potassium hydroxide and the like; and organic basessuch as mono-, di- and tri-alkyl and aryl amines (e.g., triethylamine,diisopropyl amine, methyl amine, dimethyl amine and the like) andoptionally substituted ethanol-amines (e.g., ethanolamine,diethanolamine and the like).

The peptides or salts thereof can further be derivatized to provideenhanced half-life, for example, by linking to polyethylene glycol. Thepeptides or salts thereof may comprise L-amino acids, D-amino acids(which are resistant to L-amino acid-specific proteases in vivo), acombination of D- and L-amino acids, and various “designer” amino acids(e.g., β-methyl amino acids, Cα-methyl amino acids, and Nα-methyl aminoacids, etc.) to convey special properties.

The polypeptides may be the sole active agent in the pharmaceuticalcomposition, or the composition may further comprise one or more otheractive agents suitable treating diabetic foot ulcers, such asantibiotics. The methods may be used in conjunction with other footulcer therapies, including but not limited to negative pressure woundtherapy, total contact casts, removable cast walkers, half-shoes,becaplermin, infection control, and hyperbaric oxygen therapy.

The methods may include any other embodiments as disclosed in theexample that follows. Such embodiments may be used in any combination inthe methods of the invention, unless the context clearly dictatesotherwise.

In a second aspect, the present invention provides pharmaceuticalformulations, comprising:

(a) about 0.5% to about 4% HEC on a weight (mg)/volume (ml) basis, or ona weight/weight (mg) basis; and

(b) a peptide of at least 5 contiguous amino acids of Nle3 A(1-7), orsalt thereof;

wherein the peptide is present at a concentration of about 0.03% toabout 1% on a weight (mg)/volume (ml) basis, or on a weight/weight (mg)basis.

The pharmaceutical formulations are demonstrated herein to beparticularly effective for treating diabetic foot ulcers, such aschronic diabetic foot ulcers that are not effectively treated usingstandard therapies.

In one embodiment, the peptide comprises Asp-Arg-Nle-Tyr-Ile-His-Pro(SEQ ID NO:1), or salt thereof. In another embodiment, the peptideconsists of Asp-Arg-Nle-Tyr-Ile-His-Pro (SEQ ID NO:1), or salt thereof.

In one embodiment, the peptide, or salt thereof, is present in theformulation at a concentration of about 0.03% to about 1% on a weight(mg)/volume (ml) basis, or on a weight/weight (mg) basis. In variousfurther embodiments, the peptide, or salt thereof, is present in theformulation at a concentration of about 0.03% to about 0.75%; about0.03% to about 0.5%; about 0.03% to about 0.25%; about 0.03% to about0.1%; about 0.03% to about 0.075%; about 0.03% to about 0.05%; and about0.03%; all on a weight (mg)/volume (ml) basis, or on a weight/weight(mg) basis.

In a further embodiment, the pharmaceutical formulation comprises about1% to about 3% HEC on a weight (mg)/volume (ml) basis, or on aweight/weight (mg) basis. These formulations comprising low percentageHEC (ie: 2%) matrices provided a 10-fold increase in peptide releaseover a 24 hour period from formulations such as those comprising 10%carboxymethylcellulose (CMC), a result that would be unexpected to thoseof skill in the art. Furthermore, the data show that the HEC matricesare more biocompatible than HPMC and CMC formulations tested. In a stillfurther embodiment, the pharmaceutical formulation comprises about 2%HEC on a weight (mg)/volume (ml) basis, or on a weight/weight (mg)basis. In another embodiment, the formulation comprises a hydrogelformulation.

In one embodiment, the formulation is topical gel-based formulationselected from the group consisting of hydrogels, creams, ointments,pastes, and lotions. The formulation is administered so as to form acontinuous film covering the entire area of the ulcer, including themargins, without running off. In a preferred embodiment, the topicalformulation is applied with a thickness of approximately 0.25 to 2 mm;preferably 0.5 to 1.5 mm; preferably about 1 mm in thickness. In anothernon-limiting embodiment the formulation is applied at approximately0.075 mL per cm² surface area.

In all aspects and embodiments of the invention, suitable acids whichare capable of forming salts with the peptides include, but are notlimited to, inorganic acids such as hydrochloric acid, hydrobromic acid,perchloric acid, nitric acid, thiocyanic acid, sulfuric acid, phosphoricacid and the like; and organic acids such as formic acid, acetic acid,propionic acid, glycolic acid, lactic acid, pyruvic acid, oxalic acid,malonic acid, succinic acid, maleic acid, fumaric acid, anthranilicacid, cinnamic acid, naphthalene sulfonic acid, sulfanilic acid and thelike. Suitable bases capable of forming salts with the peptides include,but are not limited to, inorganic bases such as sodium hydroxide,ammonium hydroxide, potassium hydroxide and the like; and organic basessuch as mono-, di- and tri-alkyl and aryl amines (e.g., triethylamine,diisopropyl amine, methyl amine, dimethyl amine and the like) andoptionally substituted ethanol-amines (e.g., ethanolamine,diethanolamine and the like).

The pharmaceutical formulations may further comprise (a) alyoprotectant; (b) a surfactant; (c) a bulking agent; (d) a tonicityadjusting agent; (e) a stabilizer; (f) a preservative and/or (g) abuffer. In some embodiments, the buffer in the pharmaceuticalformulations is a Tris buffer, a histidine buffer, a phosphate buffer, acitrate buffer or an acetate buffer. The pharmaceutical formulations mayalso include a lyoprotectant, e.g. sucrose, sorbitol or trehalose. Incertain embodiments, the pharmaceutical formulations includes apreservative e.g. benzalkonium chloride, benzethonium, chlorohexidine,phenol, m-cresol, benzyl alcohol, methylparaben, propylparaben,chlorobutanol, o-cresol, p-cresol, chlorocresol, phenylmercuric nitrate,thimerosal, benzoic acid, and various mixtures thereof. In otherembodiments, the pharmaceutical formulations includes a bulking agent,like glycine. In yet other embodiments, the pharmaceutical formulationsincludes a surfactant e.g., polysorbate-20, polysorbate-40,polysorbate-60, polysorbate-65, polysorbate-80 polysorbate-85,poloxamer-188, sorbitan monolaurate, sorbitan monopalmitate, sorbitanmonostearate, sorbitan monooleate, sorbitan trilaurate, sorbitantristearate, sorbitan trioleaste, or a combination thereof. Thepharmaceutical formulations may also include a tonicity adjusting agent,e.g., a compound that renders the formulation substantially isotonic orisoosmotic with human blood. Exemplary tonicity adjusting agents includesucrose, sorbitol, glycine, methionine, mannitol, dextrose, inositol,sodium chloride, arginine and arginine hydrochloride. In otherembodiments, the pharmaceutical formulations additionally includes astabilizer, e.g., a molecule which, when combined with a protein ofinterest substantially prevents or reduces chemical and/or physicalinstability of the protein of interest in lyophilized or liquid form.Exemplary stabilizers include sucrose, sorbitol, glycine, inositol,sodium chloride, methionine, arginine, and arginine hydrochloride.

The peptides or salts thereof can further be derivatized to provideenhanced half-life, for example, by linking to polyethylene glycol. Thepeptides or salts thereof may comprise L-amino acids, D-amino acids(which are resistant to L-amino acid-specific proteases in vivo), acombination of D- and L-amino acids, and various “designer” amino acids(e.g., β-methyl amino acids, Cα-methyl amino acids, and Nα-methyl aminoacids, etc.) to convey special properties.

The peptide may be the sole active agent in the pharmaceuticalcomposition, or the composition may further comprise one or more otheractive agents suitable for treating diabetic ulcers.

The formulations may include any other embodiments as disclosed in theexample that follows. Such embodiments may be used in any combination inthe formulations of the invention, unless the context clearly dictatesotherwise.

EXAMPLE Randomized, Parallel-Group, Double-Blind, Placebo-ControlledPhase 2 Clinical Trial to Evaluate the Safety and Effectiveness ofNorLeu³-A(1-7) in Treating Subjects with Diabetic Ulcers

The study was designed as a randomized, parallel-group, double-blind,placebo-controlled, multi-center trial. After 14-days of best-of-care toevaluate ulcer healing and ensure the wounds were chronic, four-weeks ofactive treatment were then followed by eight weeks of observation andassessment. The study compared the effects of two concentrations ofNorLeu³-A(1-7) and placebo, measuring both clinical efficacy and safety.Sustained tissue integrity was evaluated for all subjects during afollow-up period lasting 12 weeks after complete wound closure.

Subjects were randomized in a 1:1:1 ratio to one of the three treatmentgroups:

-   Group 1: Placebo Vehicle Control without NorLeu³-A(1-7) (also    referred to as “DSC127”) (2% Hydroxyethyl Cellulose (HEC) with 0.1%    methyl paraben, 0.02% propyl paraben)-   Group 2: 0.03% NorLeu³-A(1-7) in Vehicle-   Group 3: 0.01% NorLeu³-A(1-7) in Vehicle

The four-week treatment period required daily application of thetreatment to the wound site. The first application each week was at theclinic and for the remainder of the week the patient self-administeredthe treatment.

If wound healing occurred during the treatment or assessment periods afinal assessment visit was conducted and the integrity was assessed 4and 12 weeks later (usually weeks 16 and 24 of the study).

Inclusion Criteria

The following patients were considered eligible for participation in thestudy:

-   -   1) Male or female ambulatory subjects who were at least 18 years        of age at screening    -   2) At start of Screening Period and upon enrollment into the        study, had at least one chronic non-healing Wagner Grade 1 or        Grade 2 (ulcers of partial or full thickness and not involving        bone, tendon or capsule (probing to tendon or capsule), and that        have no sign of infection or myelitis) plantar neuropathic        diabetic ulcer between 1.0-6.0 cm² on the midfoot or forefoot,        including the toes but excluding the heel. Non-healing is        defined as present for a minimum of one month but not longer        than ten months with less than 30% reduction in size in response        to treatment (non-study treatment, but including off-loading)        during the Screening Period. If more than one ulcer is present        that meets the inclusion criteria, the larger was studied and        treated according to the protocol. Non-study ulcers were treated        according to institutional best practice, using per protocol        offloading.    -   3) Have an Ankle Brachial Index (ABI) greater than 0.7 for        neuroischemic or greater than 0.8 for neuropathic DFU.    -   4) Have a Tissue Oxygen Pressure (TcPO₂) greater than 40 mm Hg        or great toe systolic pressure greater than 50 mmHg to ensure        healing potential.    -   5) Have Type I or Type II diabetes under metabolic control as        confirmed by a glycosylated hemoglobin (HbAlc) of less than or        equal to 12%, and a serum creatinine level of no greater than 3        mg/dL obtained within 3 months of study enrollment.    -   6) Assess the baseline level of neuropathy of the foot using        Semmes-Weinstein filaments. Patients were considered to have        site specific neuropathy sufficient for loss of protective        sensation (LOPS) if they were unable to feel a #5.07        monofilament applied to at least 5 of the following 7 sites (28)        on the study foot:        -   plantar to toes and metatarsals 1, 3 and 5 (3 sites)        -   plantar to midfoot medial and lateral (2 sites)        -   plantar heel (1 site)        -   dorsal distal first interspace (1 site)    -   7) Female subjects of child-bearing potential must have negative        pregnancy test at the time of initiation of study therapy.    -   8) Female subjects of child-bearing potential must have been        willing to use a medically acceptable method of birth control,        such as Essure®, hormonal contraception (oral pills, implantable        device or skin patch), intrauterine device, tubal ligation or        double barrier, during the treatment and assessment period of        study participation.    -   9) Ability and willingness to understand and comply with study        procedures and to give written informed consent prior to        enrollment in the study or initiation of study procedures.        Exclusion Criteria

If a subject met any of the following criteria, he or she was excludedfrom the study:

-   -   1) Has a known hypersensitivity to any of the study medication        components.    -   2) Exposure to any investigational agent within 30 days of entry        into study.    -   3) Females who are pregnant or nursing.    -   4) Females unwilling to use a medically acceptable method of        birth control, such as Essure®, hormonal contraception (oral        pills, implantable device or skin patch), intrauterine device,        tubal ligation or double barrier, during the treatment and        assessment period of study participation.    -   5) Active malignant disease of any kind A subject, who has had a        malignant disease in the past, was treated and is currently        disease-free, may be considered for study entry.    -   6) Chronic renal insufficiency (serum creatinine during        screening is greater than 3.0 g/dL obtained within 3 months of        study enrollment).    -   7) Chronic liver dysfunction evidenced by transaminase levels        greater than twice normal.    -   8) Receiving hemodialysis or chronic ambulatory peritoneal        dialysis (CAPD) therapy.    -   9) Resting blood pressure (at the time of the initial visit of        the Screening Period) which exceeds 160 systolic and/or 90        diastolic mmHg on 3 consecutive readings at least 15 minutes        apart.    -   10) Prior radiation therapy of the foot with the ulcer under        study.    -   11) Current use of corticosteroids (within past 8 weeks),        immunosuppressants (within past 8 weeks).    -   12) Known to be HIV positive.    -   13) Subjects whose ulcer was primarily ischemic in etiology as        diagnosed by an ABI of <0.7 or great toe systolic pressure <40        mmHg or TcPO2<40 mmHg in the supine position and <40 mmHg while        sitting, measured on the forefoot with electrode set at 44 C.    -   14) Sickle-cell anemia, Raynaud's or other peripheral vascular        disease.    -   15) Current history of drug abuse.    -   16) Subjects receiving a biologic agent to include growth        factors and skin equivalents (Regranex™, Apligraft™, or        Dermagraft™) in the past 30 days.    -   17) Subjects with uncontrolled diabetes defined as a        glycosylated hemoglobin (HbAlc)>12%, or a serum creatinine level        of greater than 3 g/dL obtained within 3 months of study        enrollment determined on two separate occasions at least 3 weeks        apart.    -   18) Subject with an ulcer which is determined to be clinically        infected and requires topical antimicrobials or agents known to        affect wound healing or has been taking systemic antibiotics for        more than 7 days for any reason.    -   19) Subject with a Wagner Grade 3 or higher DFU, deep abscess or        infection of the joint or tendon, or gangrene or osteomyeltitis.    -   20) An EKG with a marked baseline prolongation of QT/QTc        interval (e.g., repeated demonstration of QTc interval >450        milliseconds (ms))

A total of 80 subjects were enrolled in the study; 27 were randomized tothe 0.03% dose of NorLeu³-A(1-7), 25 were randomized to placebo and 28were randomized to the 0.01% dose. All subjects also received beststandard of care, which included debridement, wound cleansing,application of an occlusive dressing and standardized properoff-loading.

Results

Recent results from a Phase 2 clinical trial with NorLeu³-A(1-7) inpatients with diabetic foot ulcers showed that the proportion of studyulcers healed by 12 weeks as defined by 100% epithelialized with nodrainage, as well as all secondary endpoints. The double-blind,placebo-controlled, multi-center clinical trial randomized 80 subjectsto receive one of two doses of NorLeu³-A(1-7) (0.03% and 0.01%) orvehicle placebo (2% hydroxyethyl cellulose in phosphate buffer with 0.1%methyl paraben and 0.02% propyl paraben) control, in addition to beststandard of care (which included debridement). The drug waswell-tolerated and there were no significant adverse events associatedwith NorLeu³-A(1-7) treatment.

In the Intent-to-Treat (ITT) population (all subjects receiving anystudy medication and from whom any post-baseline data are available):Results show that 54% of the diabetic wounds treated with 0.03% (highdose) of NorLeu³-A(1-7) achieved 100% closure in 12 weeks or less,compared with 33% of patients receiving placebo control, and 30% ofpatients receiving the 0.01% dose (low dose) of NorLeu³-A(1-7). Based onodds ratio analysis, patients treated with NorLeu³-A(1-7) 0.03% were 2.3times more likely to have their wounds heal completely as compared topatients treated with placebo/standard of care.

In the Per Protocol (PP) population (all patients that did not have amajor protocol violation affecting efficacy): Results show that 65% ofthe diabetic wounds treated with 0.03% dose of NorLeu³-A(1-7) achieved100% closure in 12 weeks or less, compared with 38% of patientsreceiving placebo control, and 28% of patients receiving the 0.01% doseof NorLeu³-A(1-7). See FIGS. 1-3. Based on odds ratio analysis, patientstreated with NorLeu³-A(1-7) 0.03% were 3.0 times more likely to havetheir wounds heal completely as compared to patients treated withplacebo/standard of care.

The high dose of NorLeu³-A(1-7) well exceeded the trial's primaryendpoint measurement target of an improvement of 15 percentage points incomplete healing of wounds within the 12-week duration of the study forboth the ITT (21% increase) and PP (27% increase) populations comparedwith placebo.

The trial was not powered for statistical significance, however therewas a statistically significant (p=0.049) 50% improvement in the rate ofhealing in the PP high-dose population through 12 weeks of treatmentcompared with the control arm, as measured by depth of ulcer usingcovariate analysis.

The wound healing rates for patients on NorLeu³-A(1-7) were remarkablewith the ITT analysis showing a 21% increase and the PP analysis showinga 27% increase over the placebo arm.

REFERENCES

-   1. American Diabetes Association, Consensus development conference    on diabetic foot wound care. Diabetes Care 1999; 22:1354-1360.-   2. Pecoraro R E, Reiber G E, Burgess E M, Pathways to diabetic limb    amputation: basis for prevention. Diabetes Care 1990; 13:513-521.-   3. Rodgers K E, Roda N, Felix J C, Espinoza T, Maldonado S, diZerega    G S. Histological evaluation of the effects of angiotensin peptides    on wound repair in diabetic mice. Experimental Dermatology 2003;    12(6):784-790.-   4. Rodgers K, Xiong S, Felix J, Roda N, Espinoza T, Maldonado S,    diZerega G S. Development of angiotensin (1-7) as an agent to    accelerate dermal repair. Wound Repair Regen 2001; 9:238-250.-   5. Rodgers K E, Espinoza T, Felix J, Roda N, Maldonado S, diZerega    G S. Acceleration of healing, reduction of fibrotic scar, and    normalization of tissue architecture by an angiotensin analogue,    Norleu³-A (1-7). Plast Reconstr Surg 2003; 111:1195-1206.-   6. Wagner, F J. A classification and treatment program for diabetic,    neuropathic, and dysvascular foot problems. Am Acad of Orthopaedic    Surgeons. Instructional Course Lecture 1979; 28:143-165.-   7. Foster A V, Eaton C, McConville D O, Edmonds M E. Application of    OpSite film: a new and effective treatment of painful diabetic    neuropathy. Diabetes Med 1994; 11(8):768-772.-   8. Sheehan P, Jones P, Caselli A, Giurini J M, Veves A. Percent    change in wound area of diabetic foot ulcers over a 4-week period is    a robust predictor of complete healing in a 12-week prospective    trial. Diabetes Care 2003; 26:1879-1882.-   9. Rodgers, K E, Abiko M, Girgis W, St. Amand K M, Campeau J D,    diZerega G S. Acceleration of dermal tissue repair by    Angiotensin II. Wound Repair Regen 1997; 5:175-183.-   10. Rodgers, K E, DeCherney A H, St. Amand K M, Dougherty W R, Felix    J C, Girgis W, diZerega G S. Histologic alterations in dermal repair    after thermal injury: effects of topical angiotensin II. Burn Care    and Rehabilitation 1997; 18:381-388.-   11. Okuyama N, Roda N, Guerrero A, Dougherty W, Nguyen T, diZerega G    S, Rodgers K E. Effect of angiotensin II on the viability,    vascularity of random flaps in a rat model. Annals Plastic Surgery    Res 1999; 68:913-918.-   12. Rodgers K E, Ellefson D D, Espinoza T, Roda N, Maldonado S,    diZerega G S. Effect of NorLeu³-A (1-7) on scar formation over time    after full thickness incision injury in the rat. Wound Repair Regen    2005; 13:309-317.-   13. Santos R A, Brosnihan K B, Chappell M C, Pesquero J, Chernicky C    L, Greene L J, and Ferrario C M. Converting enzyme activity and    angiotensin metabolism in the dog brainstem. Hypertension 1988; 11    (suppl 41-53-1-57.-   14. Santos R A S, Brosnihan K B, Jacobsen D W, DiCorleto P, and    Ferrario C M. Production of Ang-(1-7) by human vascular endothelium.    Hypertension 1992; 19 (suppl II):II-56-II-61.-   15. Santos et al. Characterization of a new angiotensin antagonist    selective for angiotensin-(1-7): evidence that the actions of    angiotensin-(1-7) are mediated by specific angiotensin receptors.    Brain Res Bull 1994; 35:293-298.-   16. Yamamoto K, Chappell M C, Brosnihan K B, Ferrario C M. In vivo    metabolism of angiotensin I by neutral endopeptidase (EC 3.4.24.11)    in spontaneously hypertensive rats. Hypertension 1992; 19:692-696.-   17. Chappell M C, Tallant E A, Brosnihan K B, Ferrario C M.    Processing of angiotensin peptides by NG108-15 neuroblastoma X    glioma hybrid cell line. Peptides 1990; 22:375-380.-   18. Chappell M C, Jacobsen D W, Tallant E A. Characterization of    angiotensin II receptor subtypes in pancreatic acinar AR42J cells.    Peptides 1995; 16:741-747.-   19. Chappell M C, Tallant E A, Brosnihan K B, Ferrario C M.    Conversion of angiotensin I to angiotensin-(1-7) by thimet    oligopeptidase (E.C.3.4.24.15) in vascular smooth muscle cells. J    Vasc Biol Med 1995; 5:129-137.-   20. Daemen M J A P, Lombardi D M, Bosman F T, Schwartz S M.    Angiotensin II induces smooth muscle cell proliferation in the    normal and injured rat arterial wall. Circ Res 1991; 68:450-56.-   21. Dzau V E, Pratt R, Gibbons G, Schunkert H, Lorell B,    Ingelfinger J. Molecular mechanism of angiotensin in the regulation    of vascular and cardiac growth. J Mol Cell Cardiol 1989; 21 [Suppl    III]:S7.-   22. Naftilan A J, Pratt R E, Dzau V J. Induction of platelet-derived    growth factor A-chain and c-myc gene expression by Angiotensin II in    culture rat vascular smooth muscle cells. J Clin Invest 1989;    83:1419-24.-   23. Stouffer G A, Owens G K. Angiotensin II induced mitogenesis of    spontaneously hypertensive rat derived cultured smooth muscle cells    is dependent on autocrine production of transforming growth    factor-β. Circ Res 1992; 70:820-28.-   24. Koibuchi Y, Lee W S, Gibbons G H, Pratt R E. Role of    transforming growth factor 13-1 in the cellular growth response to    Angiotensin II. Hypertension 1993; 21:1046-50.-   25. Kawahara Y, Sunako M, Tsuda T, Fukazaki H, Fukomoto Y, Takai Y.    Angiotensin II induces expression of the c-fos gene through protein    kinase C activation and calcium ion mobilization in cultured    vascular smooth muscle cells. BBRC 1988; 150:52-9.-   26. Mangiarua E I, Palmer V L, Lloyd L L, McCumbee W D.    Platelet-derived growth factor mediates angiotensin II-induced DNA    synthesis in vascular smooth muscle cells. Arch Physiol Biochem    1997; 105(2):151-7.-   27. Su E J, Lombardi D M, Wiener J, Daemen M J, Reidy M A, and    Schwartz M A. Mitogenic effect of angiotensin II on the rat carotid    arteries and type II or III mesenteric microvessels but not type I    mesenteric microvessels is mediated by endogenous basic fibroblast    growth factor. Circ Res 1998; 82:321.-   28. Rodgers L C. Driver V R, Armstrong D G. Assessment of the    diabetic foot. In Krasner D L, Rodeheaver G T, Sibbald R G eds.    Chronic Wound Care: A Clinical Source Book for Healthcare    Professionals. 4^(th) ed. Malvern Pa.: HMP Communications, 2007:    549-556.-   29. Bolton L, McNees P, van Rijswijk L et al. Wound healing outcomes    using standardized care. JWOCN 2004; 31:65-71.

We claim:
 1. A pharmaceutical formulation, comprising: (a) 0.5% to 4%HEC on a weight (mg)/volume (ml) basis, or on a weight/weight (mg)basis; and (b) a peptide of at least 5 contiguous amino acids of Nle3A(1-7), or a salt thereof; wherein the peptide, or salt thereof ispresent at a concentration of about 0.03% to about 1% on a weight(mg)/volume (ml) basis, or on a weight/weight (mg) basis.
 2. Thepharmaceutical formulation of claim 1, wherein the peptide, or saltthereof comprises Asp-Arg-Nle-Tyr-Ile-His-Pro (SEQ ID NO:1) or a saltthereof.
 3. The pharmaceutical formulation of claim 1, wherein thepeptide, or salt thereof consists of Asp-Arg-Nle-Tyr-Ile-His-Pro (SEQ IDNO:1) or a salt thereof.
 4. The pharmaceutical formulation of claim 1,comprising 1% to 3% HEC on a weight (mg)/volume (ml) basis, or on aweight/weight (mg) basis.
 5. The pharmaceutical formulation of claim 1comprising 2% HEC on a weight (mg)/volume (ml) basis, or on aweight/weight (mg) basis.
 6. The pharmaceutical formulation of claim 1,wherein the formulation comprises a hydrogel formulation.
 7. Thepharmaceutical formulation of claim 1, wherein the peptide, or saltthereof, is present at a concentration of about 0.03% to about 0.5% on aweight (mg)/volume (ml) basis, or on a weight/weight (mg) basis.
 8. Thepharmaceutical formulation of claim 1, wherein the formulation isselected from the group consisting of a cream, an ointment, a paste, anda lotion.
 9. The pharmaceutical formulation of claim 1, wherein theformulation further comprises one or more of (a) a lyoprotectant; (b) asurfactant; (c) a bulking agent; (d) a tonicity adjusting agent; (e) astabilizer; (f) a preservative and (g) a buffer.
 10. The pharmaceuticalformulation of claim 1, further comprising one or more other activeagents suitable for treating diabetic ulcers.
 11. The pharmaceuticalformulation of claim 4, wherein the peptide, or salt thereof consists ofAsp-Arg-Nle-Tyr-Ile-His-Pro (SEQ ID NO:1), or a salt thereof.
 12. Thepharmaceutical formulation of claim 5, wherein the peptide, or saltthereof consists of Asp-Arg-Nle-Tyr-Ile-His-Pro (SEQ ID NO:1), or a saltthereof.
 13. The pharmaceutical formulation of claim 6, wherein thepeptide, or salt thereof consists of Asp-Arg-Nle-Tyr-Ile-His-Pro (SEQ IDNO:1), or a salt thereof.
 14. The pharmaceutical formulation of claim 7,wherein the peptide, or salt thereof consists ofAsp-Arg-Nle-Tyr-Ile-His-Pro (SEQ ID NO:1), or a salt thereof.
 15. Thepharmaceutical formulation of claim 8, wherein the peptide, or saltthereof consists of Asp-Arg-Nle-Tyr-Ile-His-Pro (SEQ ID NO:1), or a saltthereof.
 16. The pharmaceutical formulation of claim 9, wherein thepeptide, or salt thereof consists of Asp-Arg-Nle-Tyr-Ile-His-Pro (SEQ IDNO:1), or a salt thereof.
 17. The pharmaceutical formulation of claim10, wherein the peptide, or salt thereof consists ofAsp-Arg-Nle-Tyr-Ile-His-Pro (SEQ ID NO:1), or a salt thereof.
 18. Amethod for treating diabetic foot ulcers, comprising administering to ahuman patient suffering from a diabetic foot ulcer an amount of apharmaceutical formulation according to claim 1 effective to treat thediabetic foot ulcer.
 19. The method of claim 18, wherein the peptide, orsalt thereof, comprises Asp-Arg-Nle-Tyr-Ile-His-Pro (SEQ ID NO:1). 20.The method of claim 18, wherein the peptide, or salt thereof, consistsof Asp-Arg-Nle-Tyr-Ile-His-Pro (SEQ ID NO:1).
 21. The method of claim18, wherein the diabetic foot ulcer is one caused, at least in part, byneuropathy and resulting pressure.
 22. The method of claim 18, whereinthe diabetic foot ulcer comprises one or more calluses.
 23. The methodof claim 18, wherein the diabetic foot ulcer is a chronic ulcer.
 24. Themethod of claim 23, wherein the chronic foot ulcer has not responded toany other treatment.
 25. The method of claim 18, wherein the peptide, orsalt thereof, is administered topically.
 26. The method of claim 25,wherein the peptide, or salt thereof, is administered as a topicalformulation forming a continuous film covering the entire area of thediabetic ulcer.
 27. The method of claim 25, wherein the peptide, or saltthereof, is administered in a hydrogel formulation.